Once a Simple Sign of Aging, Falls Now Merit Complex Care

By JOHN LELAND

Published: November 8, 2008

Katherine Aliminosa, 93, shattered her lower leg while getting snacks for her nieces.

Susan Arnold, 87, broke her hip hanging a photograph.

In mid-July, in a nursing unit of a retirement community here, the two women were at the start of a recovery process that both hoped would return them to their previous lives.

Their progress over the next few months, and their divergent outcomes, illustrate the unpredictable impact that common falls can have on the bodies of older people.

By early autumn, Ms. Aliminosa had graduated to an independent living apartment and was able to get around with a walker. She looked like a different person: more robust, content.

Though six years younger, Ms. Arnold never recovered her strength after hip surgery. Her muscles atrophied from inactivity, and she developed pneumonia. She died on Sept. 6.

Once considered an inevitable part of aging, falls are now recognized as complex, often preventable events with multiple causes and consequences, calling for a wide range of interventions, both psychological and physiological, that many patients never receive.

Even falls that cause only minor injury ''need to be taken as seriously as diabetes,'' said Dr. R. Sean Morrison, a professor of geriatrics and adult development at Mount Sinai School of Medicine in New York, because ''they can be a real warning sign that something serious is wrong.''

Dr. Mary E. Tinetti, a falls expert at Yale University medical school, compared falls to strokes in their harmfulness, adding that people do not always report them or seek help, for fear their families will try to put them in nursing homes. For some people, Dr. Tinetti said, admitting that they fall is tantamount to admitting that they are no longer competent to take care of themselves.

Each year, 1.8 million Americans over age 65 are injured in falls, according to the Centers for Disease Control and Prevention. Some rebound as if the injury never happened. But for some, the fall sets off a downward spiral of physical and emotional problems -- including pneumonia, depression, social isolation, infection and muscle loss -- that become too much for their bodies to withstand.

In 2005, the last year for which statistics are available, 433,000 people over 65 were admitted to hospitals after falling, and 15,800 died as a direct result of the fall. Less visible are the many who survive the fall but not the indirect consequences.

When first interviewed in mid-July, Ms. Aliminosa and Ms. Arnold felt vulnerable and constrained, their world diminished. Both had led accomplished professional lives -- Ms. Arnold as a school psychologist, Ms. Aliminosa as a medical researcher -- and had been active in the community's independent living apartments. But neither could be confident about what the future held.

Ms. Aliminosa said she was depressed, and able to walk only in very small stretches. A small woman with a soft voice and grainy New York accent, she barely filled her chair. She seemed defeated. ''Emotionally I have not been well,'' she said. ''It's made me very aware of my age, and that's hard to accept.''

Ms. Arnold, by contrast, was full of emotional energy, so angry about her broken hip that she kicked out for emphasis as she talked, turning conversation into a full-contact sport. Before her fall, she had been preparing for a vacation with her daughter at a family beach house on Long Island -- the same house where she had spread her husband's ashes. Now that plan was gone.

''It kills me, it just kills me,'' she said. ''This was going to be the frosting on the cake, and somebody ate it.''

Of the two women, Ms. Arnold was up against the longer odds. One in five hip-fracture patients over age 65 die within a year after surgery, according to the C.D.C.; one in four have to spend a year or more in a nursing home. When younger people fall, they tend to break their wrists catching themselves, but in older people, who have slower reactions and less upper-body strength, the weight more often falls on their hips or heads. Any underlying conditions, like heart disease or respiratory problems, increase the chances of a downward health spiral.

Ms. Arnold had a history of pulmonary disease, and had been a heavy smoker, starting after high school. ''She had a boyfriend in college,'' her daughter, Margery Creek, said, ''and it was the lesser of evils -- sex, drinking or smoking.''

But her lung problems did not keep her down. In 2006, she took a 10-day trip to Sweden. Even after she fell and fractured a hip that autumn, she lived independently and was able to drive, returning to the beach house. That day in mid-July, even as she talked about depression, she took jubilant delight in photographs of her grandchildren and great-grandchildren. ''Now if that isn't the picture of a baby,'' she said. ''Isn't she a sweetie?''

If Ms. Arnold were a machine, it would be simple to draw a straight line between her lung disease, her hip surgery and her chances of recovery. Older bodies typically have several weakened systems that are dependent on one another, and rely on drugs that may or may not work well together. ''If you take 70-year-olds, on average they're taking five medications,'' Dr. Tinetti said. ''When you get to 10 medications'' -- as a patient might after a fall -- ''the likelihood of adverse effects is close to 100 percent.''